UNAIDS 2017 | EXPLAINER

Public health and

HIV viral load
suppression
Public health and
HIV viral load
suppression
The primary purpose of antiretroviral therapy is to keep people living with HIV in good health.
In the large majority of people living with HIV, antiretroviral medication can be chosen that
reduce the amount of HIV in the blood to levels that are undetectable by standard laboratory
tests. It can take some months to reduce viral levels to undetectable levels and allow the
immune system to begin to recover. Antiretroviral therapy is transformative for people living
with HIV. It enables people to regain their quality of life, return to work, enjoy their families
and enjoy a future filled with hope.

In addition to the positive impact upon the health of people living with HIV, there is increasing
consensus among scientists that people with undetectable HIV in their blood do not transmit
HIV sexually. This knowledge can be empowering for people living with HIV. The awareness
that they are no longer transmitting HIV sexually can provide people living with HIV with a
stronger sense of being agents of prevention in their approach to new or existing
relationships.

The consensus is very encouraging for the reduction of sexual transmission of HIV among
people who are virally suppressed. Recent analyses of major studies of couples— couples of
heterosexual men and women and of men who have sex with men—in which the members
have a different HIV status from one another have not identified a single case of transmission
from a person with an undetectable viral load.1,2,3

Approximately 1.7 million adults were newly infected with HIV in 2016.4 Many of those new
infections happened in situations where people did not know their HIV status, were not on
treatment or who had started antiretroviral treatment but had not yet become virally
suppressed.5,6,7 For people in this context, HIV testing, access to antiretroviral therapy and
primary prevention with condoms, voluntary medical male circumcision, harm reduction for
people who use drugs and antiretroviral therapy-based prevention with pre-exposure
prophylaxis (PrEP) and post-exposure prophylaxis (PEP) is essential to reducing HIV
transmission.

Therefore, condom use continues to be extremely important in most contexts. Reduction in

overall condom use among people living with HIV who are not virally suppressed would have
a negative impact upon primary HIV prevention efforts. Equally, reduced condom use will give
rise to an increase in sexually transmitted infections and unwanted pregnancies.

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As important as treatment and primary prevention, systemic changes are required to scale-up
essential health services for all and to retain people in care for life. Approximately one million
people died of AIDS-related illnesses in 2016.8 Many of those deaths occurred among people
who did not seek medical attention until they became very ill, and, when they did, the health
system may have been unable to respond due to staffing shortages, poor laboratory services
or lack of medicines. Despite the remarkable scale-up of antiretroviral treatment, as many as
one third of people living with HIV do not start treatment until they are so ill that they have a
CD4 count of less than 200 cells/mm3 and are considered to have AIDS. 9

UNAIDS works to support the scale-up of comprehensive responses, including testing,

access to quality treatment and retention in care. Stronger efforts are required to ensure that
accessible, affordable and stigma-free testing and treatment, including better access to viral
load testing, is available to all people living with HIV. These efforts should address stigma,
discrimination and unjust criminalisation that violate human rights and deter people living with
HIV from accessing HIV prevention, treatment and care services.

In addition to its primary goal of keeping people living with HIV in good health, treatment and
maintaining an undetectable viral load is an important prevention tool within the combination
prevention framework. This includes male and female condoms, voluntary male medical
circumcision, PrEP and PEP and harm reduction services for people who inject drugs, along
with behaviour and structural changes. Strong condom programming is essential to ensure
sexual and reproductive health and to empower all people to be responsible for prevention,
irrespective of their HIV status.

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Key messages
1. There is growing scientific consensus that people living with HIV who are taking effective
antiretroviral therapy and whose virus is suppressed to undetectable levels will not transmit
HIV sexually.

2. Treatment is first and foremost about enabling the person living with HIV to regain and
maintain good health. Globally, there needs to be better access to viral load assays at
affordable prices, combined with effective laboratory systems and robust health services.
Stronger efforts should be in place to ensure that all people living with HIV have access to
treatment as soon as they are diagnosed.

3. The Positive Health, Dignity and Prevention10 framework of the Global Network of People
Living with HIV (GNP+) and UNAIDS lays out important principles for involving people living
with HIV and ensuring that everyone is responsible for prevention, irrespective of their HIV
status. The framework calls for ending stigma, discrimination and unjust criminalisation that
violate human rights and deter people living with HIV from accessing HIV prevention,
treatment and care services.

4. The UNAIDS Fast-Track approach and the 2016 United Nations Political Declaration on
Ending AIDS lay out recommendations that address the primary prevention and structural
changes required to reach everyone affected and to provide accessible and affordable
treatment for all people living with HIV.

5. Male and female condoms and other combination prevention strategies remain a key part
of the HIV response as primary prevention tools. Stronger condom programming is essential
to ensure sexual and reproductive health in general, not just HIV.

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 References

1. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early
antiretroviral therapy. N. Engl. J. Med 2011; 365: 493–505

2. Rodger AJ, Cambiano V, Bruun T, et al. (2106). Sexual activity without condoms and risk
of HIV transmission in serodifferent couples when the HIV-positive partner is using
suppressive antiretroviral therapy. JAMA; 316: 171-181.

3. Grulich A, et al. HIV transmission in male serodiscordant couples in Australia, Thailand

and Brazil. 2015 Conference on Retroviruses and Opportunistic Infections (CROI), Seattle,
USA, 2015.

4. Ending AIDS: progress towards the 90–90–90 targets. Geneva: UNAIDS; 2016.

5. Bluma G, Brenner MR, Routy J-P, Moisi D, Michel Ntemgwa C M, et al. (2007). High rates
of forward transmission events after acute/early HIV-1 infection. J. Infect. Dis. 195 (7): 951–
959.

6. Robineau O, Frange P, Barin F, Cazein F, Girard P-M, Chaix M-L, et al. (2015).
Combining the estimated date of HIV infection with a phylogenetic cluster study to better
understand HIV spread: application in a Paris neighbourhood. PLoS ONE 10(8): e0135367.

7. Tulio et al Transmission networks and risk of HIV infection in KwaZulu-Natal, South Africa:
a community-wide phylogenetic study de Oliveira. The Lancet HIV, Volume 4, Issue 1, e41–
e50.

8. Ending AIDS: progress towards the 90–90–90 targets. Geneva: UNAIDS; 2016.

9. Andrew F, Auld RW, Shiraishi IO, et al. (2017). Trends in prevalence of advanced HIV
disease at antiretroviral therapy enrollment—10 countries, 2004–2015. MMWR June 2, 66
(21):558–563.

10. https://www.gnpplus.net/resources/positive-health-dignity-and-prevention-operational-
guidelines/

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